State of the Art – or Counsel of Despair?
The British Medical Journal (BMJ), which boasts of being one of the world’s oldest general medical journals, from time to time publishes articles intended to guide general practitioners and other doctors on how to diagnose and treat musculoskeletal disorders. These are the very common ailments affecting the moving parts of the body (the joints, muscles, and tendons) such as low back pain, sciatica, frozen shoulder, and tennis elbow.
Unfortunately, however, all the articles I’ve seen on these problems in about the last two decades are almost counsels of despair, testifying to the bankrupt general state of knowledge in this field of medicine. They all follow the same pattern, so I’ve set out below a generic article in the style of the BMJ. All that’s needed is to fill in the blanks with the appropriate words or numbers.
State of the Art in Diagnosis and Treatment of …
Diagnosis is clinical (determined by physical examination). For details, see references [x, y] in Dutch. (Many articles in this field are from Holland.)
Most patients with [fill in the blank] will recover spontaneously within [number] weeks/months,
Watch out for ‘red flags’. (Patients with apparent ‘simple’, ‘non-specific’, or ‘mechanical’ causes of musculoskeletal pain who may have a rare serious disorder such as cancer, bone fracture, or infection.)
Offer simple, as opposed to complex, analgesia (pain killers) and advise on self care. Reassure the patient and offer an information leaflet. Recommend watchful waiting, waiting watchfully, or relative rest, i.e., doing nothing.
If the patient is not improved after [number] weeks/months or is getting worse, consider referral to physiotherapy for a course of heat and ice, rest and exercise, or an exercise class.
Do not offer X-rays or scans. Do not give injections into the [part of body].
Consider prescription of an antidepressant or anticonvulsant (these drugs, illogically, are sometimes used in refractory pain), or refer for biopsychosocial therapy from a trained [fill in the blank] therapist.
If the patient is not improved, the next step is a shared decision-making discussion about self-referral to an osteopath, chiropractor, or bone-setter for a course of manual therapy.
Alternatively, engage in a shared decision-making discussion about undergoing a course of acupuncture.
According to NASTY (National Association for Simple Treatment Yourself) guidelines, if none of this helps the patient, refer to secondary care for specialist assessment and treatment which may include any, all, or none of the following:
- Ultrasound guided cortisone injections
- Non-ultrasound guided cortisone injections
- Manipulation under anaesthesia
- Operation to remove the [fill in the blank]
It should be noted, however, that no randomised controlled trials to date have shown lasting benefit from 1. or 2. and the results from 3. are unpredictable. As for 4., this should be a last resort because systematic reviews and meta-analyses have been conflicting and some patients may end up worse than they started.
The Doctor’s Dilemma
We’re almost in the situation depicted in George Bernard Shaw’s famous play, The Doctor’s Dilemma (1906), in which a surgeon, Sir Cutler Walpole, who always recommends removal of the patient’s nuciform sac, vies with physicians, one of whom is a Dr Blenkinsop whose favourite remedy is a pound of ripe greengages every day, half an hour before lunch.
Dear reader, please believe me when I tell you I’m not just being cynical, because if you’ve ever gone to a doctor with low back pain, shoulder pain, etc., you will know what I mean. This being the case, as that horrible man Lenin asked, what is to be done?
The answer lies in the Personal View of Dr James Cyriax, published in the BMJ on 4 Novembeer 1972. You can find a link to it here. It’s well worth reading because although it was written over fifty years ago it’s still relevant today.
Here are two passages from it to illustrate the point:
‘I should have liked to call this article “The Orthopaedic Physician’s Lament,” for I have never ceased to be surprised by how long the idea of orthopaedic medicine has taken to catch on. When all is said and done, one-fifth of all family doctors’ daily work comes within this sphere. The void is so obvious, the need so great, and the advantages – humanitarian no less than financial – so clear that I had supposed that it had only to be put forward to be acclaimed at once.
‘It is my hope, in my old age, that the methods of clinical examination which I have devised, coupled with simple concepts of treatment based on such findings, will not die with me. Otherwise, they will have painfully and slowly to be rediscovered…while people and the country’s finances suffer – not because nothing can be done, but because there is no one there to do it.’ (Emphasis added.)
What about the evidence?
These days medical practice, quite rightly, is supposed to be ‘evidence based’. So what is the evidence that Dr Cyriax’s techniques work?
The problem is that the trials have not been done, so the evidence is anecdotal (based on the experience of one or more individual practitioners). For example, in patients with frozen shoulder who are diagnosed and treated according to Dr Cyriax’s methods, most recover within a short space of time. A group of patients treated in this way could be compared with another group given usual care. But here we have another problem.
There are many published trials of treatment in what is called frozen shoulder, but most of them are no good. How so? Because, incredible as it may seem, patients with pain in the shoulder region are often treated as if they’re suffering from a single disorder. But there are many causes of such pain and they all need to be distinguished so that different treatments can be compared in the same condition. The sad fact is, however, that most doctors don’t know how to carry out a systematic physical examination of the shoulder. The same applies to patients with low back pain. Again, patients with this symptom are commonly treated as if they have one and the same disorder: non-specific low back pain. This means undiagnosed low back pain, and what’s the good of that?
Dearth of orthopaedic medical practitioners
Orthopaedic medicine is the field of diagnosis and treatment of disorders of the moving parts of the body by non-operative means. I had the privilege of being taught these skills by Dr Cyriax in 1975 and in my subsequent career in general practice have used his approach in thousands of patients with regularly good results. Yet, almost forty years after Dr Cyriax’s death, to my knowledge there’s not a single hospital department of orthopaedic medicine in Britain.
While it’s true that some profit making enterprises exist in Britain and elsewhere, particularly in the progressive country of Holland, which claim to teach Dr Cyriax’s methods, the situation today is that only a few isolated practitioners who use his methods are available to help patients suffering from the above-mentioned conditions. For the rest, they have to make do with the approach indicated by the BMJ’s guidelines.
Text © Gabriel Symonds
Top picture credit: Wikimedia Commons
Greengages: Lars Blankers on Unsplash